Employer sponsored insurance, often referred to as a job-based plan or group health plan, is health insurance provided by an employer for their employees and in some cases, their families. Typically, the employer covers a portion of the premium costs, and plan options may include HMOs, PPOs, and EPOs, among others.
Any health plan you currently have through your employer (or a family member’s employer), qualifies as minimum essential coverage and you are considered covered, in compliance with the provision of the Affordable Care Act (ACA). This means that you do not need to obtain coverage through a Marketplace plan.
However, if you want to explore other options that may be available to you, such as Medicaid or a plan through the Marketplace and see how they compare to your employer plan, you can. However, there are some important things to consider before making a decision to reject your group health plan.
- Employers typically pay a portion of the premiums associated with a job-based group plan. If you choose to obtain a Marketplace plan, the employer does not contribute to your premiums.
There are two income based savings opportunities for those purchasing a plan through the Marketplace:
- Advance Premium Tax credit to help lower your monthly premium if your income falls between 100% - 400% of the Federal Poverty Level (FPL). For more information about the premium tax credit click here or contact a tax professional.
- Cost Sharing reductions, which are intended to lower the amount you have to pay for out of pocket costs like deductibles, coinsurance and copayments. These are available to those whose income falls between 100% and 250% of the FPL.
- If you decide to choose a Marketplace plan in lieu of your employer sponsored health plan, you will not qualify for the above income-based savings opportunities if your employer-based coverage is found to be affordable and meets minimum value standards.
- An employer-sponsored health plan is considered “affordable” if the employee’s share of the lowest cost self-only coverage that meets the minimum value standards is less than 9.5 % of the family’s income. Note: Affordability is determined only by the amount you pay for self-only coverage from your employer. If you pay more than 9.5% of your income for family coverage, the plan may still be considered affordable.
- A plan is deemed to meet the minimum value standard if it pays at least 60% of the total cost of medical services for a standard population.
- Job-based health plans can be either fully-insured or self-insured. It is important to understand the difference between the two plan types because self-insured plans are not required to comply with all provisions of the ACA.
Choosing the health plan that is right for you and your family is one of the most important decisions a family affected by a bleeding disorder must make. It is important to weigh your options carefully before making a decision. NHF's Personal Health Insurance Toolkit is one resource designed to help guide you through the evaluation process. Other resources include your local chapter, your hemophilia treatment center social worker and www.healthcare.gov.
The information on this page is provided for informational purposes only and is not intended to provide advice about your eligibility for any program or any particular insurance product for you or your family. If you have questions about whether you qualify for your employer’s insurance plan or whether your employer’s plan is affordable and meets minimum value standards, please contact your employer, tax professional, or Marketplace (www.healthcare.gov) for additional information.